H1n1

[Jeff698]

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I can't believe this hasn't come up yet 'cause I'm pretty sure our's isn't the only ED being overrun by this damn bug and people deathly afraid of it.

How are y'all dealing with the non-sick with 'flu like symptoms'?

Our lab will only run the rapid flu test on patients under 5 years old because of the horrible sensitivity over that age range.

Our hospital is telling us not to run the PCR test (which has decent sensitivities apparently) on patients not in a high risk group because it costs about $600 and shouldn't alter therapy.

If we do sent the PCR, assuming the lab will actually run it, the results won't be available until the next day. This is both useless for us in the ED and puts most patients out of the range of what little benefit Tamiflu can give.

We're now getting word from some local pharmacies that they won't fill Tamiflu prescriptions without verification of a positive flu test. Which we can't provide.

Our patients are showing up wanting both a rapid flu test and an Rx for Tamiflu to protect them against the killer swine flu. They can get both at from the NP staffing the clinic at the CVS and they don't understand why we can't provide it at our hospital. They aren't all that interested in hearing a discussion about CDC recommendations and the sensitivities of rapid flu tests, assuming I had time to get into it with them, which I don't.

So... I'm feeling particularly squeezed by this bug. Our volumes are steadily rising because of it. We're seeing upwards of 40-50 patients on our 12 hour days shifts (single coverage) with 6-10 of them being flu like. I'm frustrated.

How are y'all dealing with this? Anyone in a similar pickle?

Take care
Jeff

 

[DocVirk]

Our hospital (residency program, community/academic mix) has stopped running rapid flu on anyone who is not really sick or not high risk. Same with Tamiflu.
We have put up signs all over warning people that they will probably not be tested and not receive tamiflu, but it hasn't helped too much. Our volume is way up (especially in peds), our wait times are up, and our Left Without Being Seen is up over 15 percent (usually 3-5). It's pretty much a terrible situation, and we definitely aren't giving people what they want. Haven't seen any patient satisfaction numbers, but I'm sure they're through the floor.
All of this is complicated by the fact that a 12 year old kid, severely ill with other medical problems, recently died at our institution from H1N1 and it was all over the news. Now everyone thinks that they're going to die from it.

What we really need is a much better public education campaign. The CDC needs to come out with some highly publicized guidelines about who needs to be seen by a doctor, who needs to be seen at an ED, and who needs to sleep it off at home.

Some of the worst culprits, by the way, are the schools. If a kid gets anything that looks like a cold or flu, they are not allowed back to school without a doctors note. Since the PCP clinics are swamped, everyone comes to the ED.

 

[Arcan57]

We're seeing about 70 more patients per day then we were this time last year. Our peds volume has at least doubled. Since our wait times have exploded, most of the patients I'm seeing have already had a rapid flu performed in the lobby. I treat positives if they're within the window, otherwise if the story sounds like flu and its <48hrs then I'll treat. I want to put up a sign in the waiting room saying "If you think you have the flu, don't register unless you can't breath". I'm told by administration that the sign would be a violation of EMTALA. I'm just praying that H1N1 burns out before the seasonal flu hits.

 

[WilcoWorld]

CDC Q&A re. Revised Antiviral Recommendations http://www.flu.gov/vaccine/antiviralfaq.html
o Consider providing antiviral prescriptions to high-risk patients before they are symptomatic, to minimize time to treatment.
o Antiviral drugs should not be used for prophylaxis in healthy persons with a history of community exposure.
o Patients prioritized for treatment are:
§ People hospitalized with suspected or confirmed influenza
§ People with suspected or confirmed influenza who are at higher risk for complications:
§ children younger than 5 years
§ adults 65 years and older
§ pregnant women
§ people with certain chronic medical conditions (including pregnancy) or immunosuppressive conditions
§ People < 19 year who are receiving long-term aspirin therapy
o Any suspected influenza patient who presents with emergency warning signs (for example, difficulty breathing or shortness of breath) or signs of lower respiratory tract illness should promptly receive antiviral therapy.
o Antiviral drugs should be started within 2 days after becoming sick. They can reduce the severity of flu symptoms and shorten the course of illness by 1-2 days. They may also prevent complications.
o Antiviral drugs are about 70-90% effective against susceptible viruses.
o The recommended course of treatment is five days. More severely ill patients may require longer treatment.
o "Antiviral chemoprophylaxis generally should be reserved for people at higher risk for influenza-related complications who have had contact with someone likely to have been infected with influenza."
o "Post-exposure antiviral chemoprophylaxis can be considered for health care personnel, public health workers, or first responders who have had a recognized, unprotected close contact exposure to a person with confirmed, probable, or suspected 2009 H1N1 or seasonal influenza during that person's infectious period."
o "Duration of antiviral chemoprophylaxis post-exposure is 10 days after the last known exposure."
o "Oseltamivir and zanamivir are "Pregnancy Category C" medications, indicating that no clinical studies have been conducted to assess the safety of these medications for pregnant women. Pregnancy should not be considered a contraindication to oseltamivir or zanamivir use. Because of its systemic activity, oseltamivir is preferred for treatment of pregnant women."
o Oseltamivir's commonest side effects or nausea and vomiting. The FDA also notes post-marketing reports of delirium and self-injury.

 

[WilcoWorld]

Looks to me like the CDC says it's OK to give Tamiflu if Dr. Jeff wants to write for it. Clinical suspicion beats rapid testing during endemic times, and H1N1 is causing the majority of flu now. What gives with your pharmacys requiring documented H1N1?

 

[Stitch]

Looks to me like the CDC says it's OK to give Tamiflu if Dr. Jeff wants to write for it. Clinical suspicion beats rapid testing during endemic times, and H1N1 is causing the majority of flu now. What gives with your pharmacys requiring documented H1N1?

The CDC recs are pretty worthless. A good 75% percent of what walks through my doors is a kid with fever and some sort of respiratory symptom. Apparently I should offer treatment to everyone one of the under 5. Our volume is also up, but it hasn't been terrible. Yet. I'm not testing everyone, for the same reasons you guys aren't. Ultimately I go by risk factors and clinical presentation.

Supposedly our hospital admin is meeting with the local news people, both TV and paper. Maybe that will help any craziness, but I don't have high hopes. A PR plan is key to surviving this season, however.

Refusing to provide Tamiflu without a positive test is ridiculous. Anyone sit down with those idiots and explain the sensitivity of testing??

Anyone see the recent article evaluating Tamiflu in adults? Doesn't appear that it's all that useful.

 

[WilcoWorld]

I respect your right to disagree with/criticize the CDC recs. My point is that if the CDC says antivirals should be given to "Any suspected influenza patient who presents with emergency warning signs (for example, difficulty breathing or shortness of breath) or signs of lower respiratory tract illness" Then if Jeff determines a script is indicated, then the pharmacy has no right to demand laboratory confirmation. My hospital pharmacy requires that I document high risk or signs of severe illness to give oseltamivir, but the latter category is essentially a clinical decision, and that decision belongs to the doctor - not the pharmacy or the lab.

 

[SoCuteMD]

?? Are the EDs I work in the ONLY ones not seeing this. I seriously don't think I saw one patient who mentioned swine flu to me. I saw lots of peds fevers, a few adult, but that's it at our community hospital. I've been away from our University ED for a bit, but my fellow residents have said it's not too bad.

Weird.

 

[Stitch]

I respect your right to disagree with/criticize the CDC recs. My point is that if the CDC says antivirals should be given to "Any suspected influenza patient who presents with emergency warning signs (for example, difficulty breathing or shortness of breath) or signs of lower respiratory tract illness" Then if Jeff determines a script is indicated, then the pharmacy has no right to demand laboratory confirmation. My hospital pharmacy requires that I document high risk or signs of severe illness to give oseltamivir, but the latter category is essentially a clinical decision, and that decision belongs to the doctor - not the pharmacy or the lab.

I was actually agreeing with you, especially about the lab requiring testing. The recs leave it open to your (or Jeff's 🙂) clinical judgement and discretion. My complaint is that they aren't very helpful in coming to that decision. Sorry if that didn't come through.

 

[Jeff698]

What are y'all doing about testing, as in what do your shops have available?

I agree completely about not needing any test for the vast majority of patient, as well as the vast majority not needing an Rx (or, if I deem they need it then it shouldn't require a test), I'm just curious if anyone else is feeling put in a bind.

We're apparently working on a flyer to be distributed in our waiting room, helpfully placed where people will have to pass it enroute to registration, saying that testing isn't helpful and outlining the CDC's recommendations. It will also tell them we can't offer the test so, if that's all their there for, they should save their co-pay.

Take care,
Jeff

 

[WilcoWorld]

Stitch - I agree with you. PR is important. In fact, I think that if we could get people to understand what they do vs what they don't need to come in for w/r/t the flu and thereby reduce spread to the other people in the waiting room (ours was up to sixty last week - ug) then we would probably reduce the spread of flu more than we could with mounds of Tamiflu.

SoCute - Back in April/May we got swamped by a swine flu scare, and our ED's well-intentioned-but-cumbersome response (triaged flu symptoms to decon, had to walk half way across the building to see 'em, and you might as well print your d/c instructions before you go there, since you'll probably d/c them immediately anyway and of course decon doesn't have a printer).

The funny thing is that I haven't had any patients ask specifically about swine flu in months. But I have seen what I think was the flu (and thus likely to be H1N1) six times this month - only tested the one I admitted (who had metastatic breast cancer and several abnormal vitals).

 

[hyperbaric]

?? Are the EDs I work in the ONLY ones not seeing this. I seriously don't think I saw one patient who mentioned swine flu to me. I saw lots of peds fevers, a few adult, but that's it at our community hospital. I've been away from our University ED for a bit, but my fellow residents have said it's not too bad.

Weird.

We were seeing enough + rapid screens that we are now only screening those at extremes of age or with comorbidities. At one point there were severals residents (and nursing/staff) out with documented flu. Now any patient with fever or URI-like complaints is getting masked at the door.

 

[Seaglass]

I worked 3 peds ED shifts over the weekend. I think about a third of the kids I saw were febrile respiratory illness. We are complying with the CDC recs and all the kids under 5 got treated and I also wrote scripts for family members who are in at risk groups. We are only testing admitted patients with the PCR test, no rapid flu swabs. We are seeing so much flu that if someone comes in with febrile URI type illness that isn't PNA or strep then I tell them they probably have the flu and explain why they aren't going to get testing or tx. Has gone pretty well so far.

 

[dchristismi]

We are swamped with it - volumes are way up and it's been a frustrating madhouse. We ordered tents, apparently, for when it gets even worse, to be our new triage.

We aren't testing much at all anymore given the poor sensitivity of the test. Still we do test some kids and most pregnant women, and anyone intubated or hospitalized with flu-like crap. We only have the nasal swab rapid test to my knowledge, and I've told plenty of people that even though they tested negative, they had classic symptoms and I was pretty sure it was the flu.

The fear is ridiculous and palpable. People don't get it. If you have a fever, cough and body aches, you have the flu. We have flyers at triage, but they haven't changed anything.

Most of us aren't writing for tamiflu anymore as there is a significant shortage in our area, and there are some concerning side effects (See Annals article about prophylaxis in Japan making little kids crazy). Last I heard, none of the pharmacies in the area had liquid tamiflu at all. It isn't a silver bullet, and costs about $120 out of pocket at our local Walgreens. (We called and asked.) We are seeing a lot of people out of the window anyway. Most of us were writing for it a few weeks ago, but that has changed. Seems like things are constantly changing.

The "It's not like amoxicillan when you have strep throat" lecture sort of works. They seem to understand that, especially when you emphasize that it only lessens the misery a little bit for maybe one less day. We are de-stressing Tamiflu a lot.

If you're pregnant, I'll write for it. Asthma or other comorbidities? Maybe. Healthy average person (including children), nope.

 

[Arcan57]

Actually, there are a lot of similarities between tamiflu for influenza and amoxicillin for strep throat. Neither one is very good at providing symptomatic relief, and they're both used in the hopes of a slight improvement in length of symptoms and a miniscule chance of preventing severe badness.

I know what you mean, it's just frustrating on top of this flu crap that 15-20% of my patients last shift had seen another health care provider within 48 hours and been diagnosed with a URI. I'm not sure how quickly people think Z-paks cure URIs, but the fact that you still feel as crappy on day 4 as you did on day 2 is not a reason to go to the ED!

 

[southerndoc]

Here in Georgia, we are having widespread flu activity. We were testing for it when it first started, but we found that 30% of patients were falsely negative by the rapid flu test. Out of all the patients who were flu A positive, 100% have been novel H1N1.

We are now only testing individuals sick enough to be admitted. Those who are likely to be discharged get symptomatic treatment (cough syrup, etc.) only. Those with risk factors (as quoted above: basically <5 years of age, >65 years of age, history of asthma, diabetes, or immunocompromised) get a Tamiflu script if they have <48 hours of symptoms. Most of these high risk patients will be sick enough to get admitted anyhow.

The local news stations have been really good about telling people if you have the flu, don't go to the ER because you won't be treated.

 

[Apollyon]

The Tamiflu is ironic, because DocB posted some years ago about writing Rx for it; people wanted an Rx, so they got it, but, because it's so expensive, they didn't fill it.

 

[gutonc]

Our lab yanked the rapid flu test completely throughout the hospital, even in the ED. PCR only for high-risk populations.

 

[Jeff698]

I got my butt kicked today. A record number of patients for me (and for the department) with a full 33% of them being for flu-like symptoms.

Dell Children's, the peds center to our south, apparently gave in to the inevitable today and opened up their "flu tent" to fast-track/sequester their febrile URI types. Here are some URLs: http://www.statesman.com/news/content/multimedia/players/brightcove.html?bcpid=1459162514&bclid=1461295911&bctid=41365568001 and http://www.statesman.com/news/content/news/stories/local/2009/09/22/0922swineflu.html

It's about to get out of control in our little neck of the woods.

Take care,
Jeff

 

[southerndoc]

Our new FastTrack area is all under negative pressure. We've termed it "FluTrack" for now because all patients with flu-like symptoms go there unless they are really sick, and then they get a negative treatment room in the main treatment area.

 

[GeneralVeers]

This is a situation where the medical screening exam, followed by the $50 co-pay would help thin the ranks.

 

[WilcoWorld]

It arrived here in force last week and yesterday our Peds ED census alone was about what we'd see in the whole ED on a bad day.

Someone please make it stop.

 

[Apollyon]

Hehe - no H1N1 here in Hawai'i - just a likely ACTIVE TB in a 17 month old yesterday. Lovely. Mom didn't even react when I told her that's what it looked like on his chest X-ray.

Highest incidence of TB on Earth? Marshall Islands. Also high numbers in Guam and from the poor in the Philippines. And who is coming to Hawai'i? Same.

 

[Stitch]

Hehe - no H1N1 here in Hawai'i - just a likely ACTIVE TB in a 17 month old yesterday. Lovely. Mom didn't even react when I told her that's what it looked like on his chest X-ray.

Highest incidence of TB on Earth? Marshall Islands. Also high numbers in Guam and from the poor in the Philippines. And who is coming to Hawai'i? Same.

😱
I find that more scary, honestly. Especially the multi drug resistance from people who are non compliant with their meds.

Remember, if a kid has it, someone needs to find the adult that gave it to him.

 

[TysonCook]

Our problem is that the patients are all well, know they are well, aren't concerened about the flu symptoms......but heres the kick in the b#lls...

The local school district requires a doctors note to miss school, so when they can't get into the PCP, or don't have a PCP, they come to the ED. I had 4 patients last night who specifically required a doctors note to stay home, in addition to the "flu crowd".

I'm seriously going to write a letter to the superintendant of schools today...

I don't test unless <5yo, and don't treat unless w/in guidelines. I do use some lortab for the myalgias/cough (and have the patient combine w/OTC cough meds if desired) as Rx are expensive. I've been skipping Tamiflu unless warrented.

 

[WilcoWorld]

Agreed - Work/school excuse requirements should be waived during this time. It's better for the school, for the employer, for the patient, for society and for us.

Are you guys treating after 48 hours of symptoms? The data suggests no benefit, but the data wasn't on H1N1 specifically. Yesterday I had a young woman with an early pneumonia on CXR who was non toxic, non tachypneic, non hypoxic and on her 4th day of illness - I treated for pneumonia, but didn't give oseltamivir. I think it was the right decision based on available information, but I wonder what the rest of y'all are doing.

 

[Stitch]

Agreed - Work/school excuse requirements should be waived during this time. It's better for the school, for the employer, for the patient, for society and for us.

Are you guys treating after 48 hours of symptoms? The data suggests no benefit, but the data wasn't on H1N1 specifically. Yesterday I had a young woman with an early pneumonia on CXR who was non toxic, non tachypneic, non hypoxic and on her 4th day of illness - I treated for pneumonia, but didn't give oseltamivir. I think it was the right decision based on available information, but I wonder what the rest of y'all are doing.

I'm not treating if they've had symptoms for >48 hours, and I explain to the patient why. Anyone sick enough to be admitted for flu is being treated with Tamiflu by our hospitalist service regardless of duration. Here are the current CDC recommendations.

 

[WilcoWorld]

Sound like we're doing the same thing. I have also read the CDC recs, and what I don't like is the vagueness of the stance on > 48 hours of symptoms:

"Treatment, when indicated, should be initiated as early as possible because studies show that treatment initiated early (i.e., within 48 hours of illness onset) is more likely to provide benefit."

That makes it sound like 72 hours is still better than 96 hours, but we all know (you, me, and the CDC) that treating someone on day 3 or 4 of illness is probably just going to deplete the supply of meds, not change the course of the illness.

 

[nlax30]

Did my peds rotation (mostly outpatient) last month and lucky for me the rotation started right around the same time a lot of local schools started back and on my first day we had a half dozen +Flu A's on the nasal swab rapid tests, not including negatives that were still suspicious clinically for Flu.

In the beginning my attending was pretty much treating everyone who tested positive along with prophylaxis for high risk family members. For the rest of the month we had at least 2 confirmed Flu A's each day in the office, youngest being a 2month old who really wasn't that sick but still prompted a quick call to our local peds ID doc.

Towards the end of the month we weren't really treating everyone, just the more high risk groups like ya'll have already mentioned. It also helped to call a few of the local pharmacies up to see what their stock situation was and found a couple local stores who could do some compounding as we had a fair number of younger children/infants who needed dosages that were getting harder to find.

It definitely blew up around this area once schools opened back up this year.

 

[Apollyon]

😱
I find that more scary, honestly. Especially the multi drug resistance from people who are non compliant with their meds.

Remember, if a kid has it, someone needs to find the adult that gave it to him.

Somehow, we found out today that it was/is just a garden variety PNA, and not TB - as I thought that the standard was 3 negative sputa, and this is only 2 days, I'm not sure how they came up with that.

Oh well.

 

[Katydid]

Somehow, we found out today that it was/is just a garden variety PNA, and not TB - as I thought that the standard was 3 negative sputa, and this is only 2 days, I'm not sure how they came up with that.

Oh well.

Still pretty scary, in my non-medical opinion.

And I'm still 😱 that the kid's mom didn't even bat an eye over the possibility of active TB in her child. Really? I'd have been extremely upset, although trying to keep calm for the sake of the child.

And speaking of H1N1, I haven't *heard* of a lot of cases around here, not in a while at least, but back where I'm from (KY), my friends are telling me that it's been going around.

Guess where we're moving to in about three weeks?

 

[Stitch]

Somehow, we found out today that it was/is just a garden variety PNA, and not TB - as I thought that the standard was 3 negative sputa, and this is only 2 days, I'm not sure how they came up with that.

Oh well.

They may have used a morning gastric aspirate instead. It's hard to get reliable sputum from a kid that age, and often they can't produce it. Still, if the incidence is high (and it sounds like it is), I'd be pretty cautious about ruling it out.

 

[Apollyon]

Auntie got really agitated, but Mom just didn't bat an eye.

One of the radiologists told me on the telephone that mainlanders don't think of it, but TB has to be high on your Ddx, because you WILL see it here.

 

[pseudoknot]

Somehow, we found out today that it was/is just a garden variety PNA, and not TB - as I thought that the standard was 3 negative sputa, and this is only 2 days, I'm not sure how they came up with that.

Oh well.

I was told recently they just had to be 3 separate samples, and could even be collected at the same time. I haven't been able to find any literature that addresses this one way or the other.

 

[KidDr]

It arrived here in force last week and yesterday our Peds ED census alone was about what we'd see in the whole ED on a bad day.

Someone please make it stop.

I'm in the peds ED--our numbers are through the roof these days. And some of the kids with H1N1 are really sick and actually belong in the ED (myocarditis, shock, severe pneumonia, severe dehydration, complex febrile seizures, etc, etc, etc).
I suspect that I'll prescribe more Tamiflu this year than all of the subsequent years I'll be in practice--combined.
Can't wait until we add RSV to all of this...that'll be fun🙄

One practical question that is starting to come up as we enter the 2nd and 3rd months of this fall's H1N1 season--what are you guys doing when a young kid (or anyone who would qualify for treatment with Tamiflu according to the CDC guidelines) comes in with an ILI and has already been treated with a course of Tamiflu within the past month or two for a separate ILI? Are there any official guidelines out there for these cases? If the kid is sick enough to be in the hospital, our hospitalists get to make that call (and I suspect most of these kids are getting the Tamiflu, even if it's a second course). But for kids I'm discharging home, at this point, I'm treating with a 2nd course only if I have a confirmed case of Influenza A (which rarely happens, because it's rare that I would have this info--I'm only doing rapid influenza nasal washings in rare cases, and we all know their sensitivity sucks). I might consider a 2nd course in a higher risk kid (i.e. less than 2 years old AND a h/o asthma or congenital heart disease or what not) with what I would consider a pretty convincing current ILI (high fever, ST, cough, body aches, red eyes--and not just a low-grade fever and runny nose).

This practice isn't based on any guidelines at all (mostly it's based on discussions I've had with colleagues)--hence I'm curious what everyone else is doing.

Oh and I just got my H1N1 nasal vaccine...here's to hoping it's effective!!

 

[beanbean]

We haven't been hit as hard as some areas. One of the biggest issues is trying to find beds for the patients that need to be admitted on isolation precautions. The hospital has very few private rooms and right now anyone with fever and respiratory symptoms needs to be on isolation until they are ruled out as flu. As of now they don't want to cohort these patients together because you might be placing Grandma with her COPD and PNA in a room with someone with H1N1. We are still doing the rapid flu on admitted pts because if you do get a positive on two pts then they can be roomed together, but a negative rapid test is not enough to clear you from isolation. The bottom line is when this hits as it has in other areas the ED will be overflowing with boarded patients with no rooms upstairs. The hospital is already near capacity and it won't take much to really push us over the edge.

 

[WilcoWorld]

Since the H1N1 wave seems to have preceded the predicted "seasonal" flu strain it seems that it would be reasonable to treat a second ILI with Tamiflu, as it could be a different strain of flu. Of course I assume you are not talking about those who get worse soon after an ILI, in which secondary bacterial pneumonia is of course a more likely cause.

But yeah, it's pretty scary to think that we're not just barely into the traditional flu season, and that the best may yet be to come...

 

[KidDr]

We haven't been hit as hard as some areas. One of the biggest issues is trying to find beds for the patients that need to be admitted on isolation precautions. The hospital has very few private rooms and right now anyone with fever and respiratory symptoms needs to be on isolation until they are ruled out as flu. As of now they don't want to cohort these patients together because you might be placing Grandma with her COPD and PNA in a room with someone with H1N1. We are still doing the rapid flu on admitted pts because if you do get a positive on two pts then they can be roomed together, but a negative rapid test is not enough to clear you from isolation. The bottom line is when this hits as it has in other areas the ED will be overflowing with boarded patients with no rooms upstairs. The hospital is already near capacity and it won't take much to really push us over the edge.

We're also doing rapid influenza tests on admitted patients (takes a couple hours to come back) as well as the confirmatory H1N1 testing (takes a couple days to come back). Most of our rooms are single rooms, but for doubles, we will cohort patients who are both positive. A negative test is pretty worthless in my opinion--if someone has an ILI and they're sick enough to get admitted, they're going to be isolated and they're getting Tamiflu.

Our ED has been overflowing and we've been boarding patients intermittently when it gets really bad. Luckily for us, we've established some overflow areas in the nearby short stay unit (which usually has space for us to overflow) and so far we've usually had enough nursing staff to send up to 4-5 boarders back there with a nurse until the floor can finally take them (most are boarding for 8-12 hours, some longer). It really helps.

 

[KidDr]

Since the H1N1 wave seems to have preceded the predicted "seasonal" flu strain it seems that it would be reasonable to treat a second ILI with Tamiflu, as it could be a different strain of flu. Of course I assume you are not talking about those who get worse soon after an ILI, in which secondary bacterial pneumonia is of course a more likely cause.

But yeah, it's pretty scary to think that we're not just barely into the traditional flu season, and that the best may yet be to come...

Exactly--I'm talking about kids with truly separate ILIs (i.e. at least a week of no symptoms between the ILIs, so my concern for secondary bacterial infection would be very low). We don't have any seasonal influenza A or B here yet, so if I'm considering treating a second ILI with Tamiflu, one of a few possibilities is going on:

1) Their 1st ILI was H1N1 and this ILI is whatever other virus is going around that can cause ILIs (parainfluenza, parvovirus, roseola, RSV, and on and on), and Tamiflu won't have any benefit
2) Their first ILI was another virus that causes ILIs and Tamiflu did nothing for them, but this current ILI is H1N1, and Tamiflu might be beneficial, but I'm not giving it to them because they already got Tamiflu for their non-H1N1 virus
3) Neither of their ILIs is H1N1...which is definitely possible. Infants and children (especially those in day care) can get several ILIs each winter...

And like you said, when we DO add regular seasonal influenza to this, that will just add to the fun! 🙂
I suspect at that point that I might be more likely to treat with a 2nd course of Tamiflu. I hope the CDC comes out with guidelines regarding this soon. Not so much because they have the data to support any of these practices, but because then at least I can point to CDC guidelines to justify what I'm doing (or not doing).

 

[DocVirk]

How many of your residents or staff have started getting sick? At our program it's definitely started to make the rounds. I'm holed up in bed with something (I strongly suspect H1N1), and I know that three or four other residents have had similar infections.

We are pretty good about getting people on tamiflu and getting shifts covered, but it's to the point where it's getting ridiculous. I'm pretty sure I'm going to end up working while I'm sick just because we can't afford the call-outs anymore. I think this will just get worse throughout the winter as well.

On another note, I don't understand why the average healthy 22-year-old insists on coming to the ED for this. I feel like crap, have body aches, high fevers, chills, and a cough, but I can drink gatorade and take tylenol at home. Man up, people.

 

[WilcoWorld]

How many of your residents or staff have started getting sick? At our program it's definitely started to make the rounds. I'm holed up in bed with something (I strongly suspect H1N1), and I know that three or four other residents have had similar infections.

We are pretty good about getting people on tamiflu and getting shifts covered, but it's to the point where it's getting ridiculous. I'm pretty sure I'm going to end up working while I'm sick just because we can't afford the call-outs anymore. I think this will just get worse throughout the winter as well.

If this problem continues after the seasonal and H1N1 vaccines have been available I'll be pretty upset with anyone who declined the shot that gets me called in. Health care workers who don't get vaccinated this year (or any, really) are not just stupid, but also selfish.

It's called herd immunity people, it works.

 

[Stitch]

If this problem continues after the seasonal and H1N1 vaccines have been available I'll be pretty upset with anyone who declined the shot that gets me called in. Health care workers who don't get vaccinated this year (or any, really) are not just stupid, but also selfish.

It's called herd immunity people, it works.

Is your institution requiring them? Ours made a big stink about it. At first they were saying they wouldn't allow anyone to work who wasn't vaccinated, but now state that if you aren't documented as being vaccinated, then you have to wear gloves, gown and mask for your whole shift. This approach seems to be working.

Nonvaccinators piss me off.

 

[KidDr]

Not requiring them, but anyone who does not get the vaccination is required to wear a mask the whole time (sounds kind of lame). IF they get sick, they are out a minimum of 7 days.

Anyone, patients continue to come in to the ED and its getting bad. We have all new protocols on where to have patients wait, set up new triage areas, etc.. but no plans to add new PA's, providers, etc..

And patients continue to get annoyed when you tell them there is nothing to do for them, and that we are not doing flu testing unless they are admitted. Alot also come in because "they just want to make sure they dont have the swine flu", and then I tell them they probably do. And dont get me started on all the "work-note" visits. Also, we have been having multiple cases of hospital-acquired H1N1 in our ICU patients. They are trying to tell people to stay home in the local media, BUT NO ONE IS LISTENING. Its very frustrating, and is going to be a bad winter.

completely agree with all of your frustrations...I wish I could make a tape recording of myself saying my H1N1 spiel...I just say the same things over and over again all day/night...no a fever of 104 alone doesn't mean your kid (who's now running around the room) is dying, no I'm not going to do a flu test on him, no he doesn't need Tamiflu, no you don't need Tamiflu prophylaxis, push fluids, give fever meds, bring your child back if he gets worse, yada yada yada

 

[beanbean]

Had a couple of kids last night that probably had H1N1 and wrote Tamiflu for one based on chronic medical issues which made her moderately high risk. One mother brought her 16 yo son to the ED at 3am for a "fever" and sore throat. No respiratory symptoms. She thought 98 degrees was a high fever and was pissed we were not testing and or treating for flu. Turns out he had flu last spring and was treated with Tamiflu. So now she wants Tamiflu every time he gets a sniffle. She complained "Thats all" when I told her he should take Ibuprofen and Tylenol. She then complained "Why should I have to give him both?"

There is no reasoning with ignorance and no educating when people think they know everything.

I shouldn't complain. I would rather see these kids all night rather than have to see another baby with 2nd and 3rd degree burns over his scalp like the poor little guy I had last night.

 

[Jeff698]

I feel your pain. I'm seeing between 15 and 20 of these a day now in our "quiet" little community ED. Each one turns into an uphill education session battling the forces of media "education", schools that tell parents to rush their child to the ED for their temperature of 103 and Oprah peddling her vaccine nonsense.

One of my nurses got pissed at me the other day because I'm getting so frustrated with all of these folks. She keeps saying "yeah, the department and waiting room are full and you're the only doc, but so what, they're not sick".

What she (and most of the media) overlook is that an ED full of well people is like looking for a needle in a big a** haystack. You know there's a sick person in there somewhere but there's an awful lot of time-consuming hay to move out of the way before you find them.

I'd like to think there's a light at the end of the H1N1 tunnel, but I suspect it's just the oncoming seasonal flu train.

Take care,
Jeff

 

[Apollyon]

If your "quiet" ED is seeing 20 of these a day, that's 0.83 patients per hour. That is already cutting into your PPH numbers, and above 2.6 (as you know, unless it's the Peds ED exclusively) is grinding you to a nub.

 

[Jeff698]

If your "quiet" ED is seeing 20 of these a day, that's 0.83 patients per hour. That is already cutting into your PPH numbers, and above 2.6 (as you know, unless it's the Peds ED exclusively) is grinding you to a nub.

Yes, that's my point. Well, sort of. It isn't 20 a day. It's 20 during the day shift. There are more at night. We're not a peds ED and we're drowning in H1N1 kids. In single coverage, I'm seeing between 36 and 50 total in a 12 hour shift. This is a big increase from our pre-H1N1 baseline.

I'm a crispy doctor nub, to use your word (which I think I'll repeat a few times 'cause it has some nice double meanings). Our volume continues to increase as a result of this lunacy. While increasing volumes are a good thing (generally), without more docs I'm back to my needle in a haystack analogy looking for the sick people in the valley of the well.

I'm hearing anecdotal reports from my other EM buds that this seems to be the same in most of the high prevalence areas. Hopefully, the madness will stop soon!

Take care,
Jeff

 

[WilcoWorld]

Yes, that's my point. Well, sort of. It isn't 20 a day. It's 20 during the day shift. There are more at night. We're not a peds ED and we're drowning in H1N1 kids. In single coverage, I'm seeing between 36 and 50 total in a 12 hour shift. This is a big increase from our pre-H1N1 baseline.

I'm a crispy doctor nub, to use your word (which I think I'll repeat a few times 'cause it has some nice double meanings). Our volume continues to increase as a result of this lunacy. While increasing volumes are a good thing (generally), without more docs I'm back to my needle in a haystack analogy looking for the sick people in the valley of the well.

I'm hearing anecdotal reports from my other EM buds that this seems to be the same in most of the high prevalence areas. Hopefully, the madness will stop soon!

Take care,
Jeff

I thought we had it bad, but I'd be toast with those numbers - you have my sympathy.

 

[Apollyon]

I thought we had it bad, but I'd be toast with those numbers - you have my sympathy.

Yeah, boy howdy - that is ROUGH, like "I forgot to buy toilet paper and need to use paper towels" rough.

 

[Jeff698]

Yeah, it's not pretty. I find myself in a corner, sucking my thumb and the end of most shifts. Hopefully, it'll get back to normal after the craziness dies off.

BTW, paper towels beats pine needles.

Or so I'm told.

Take care,
Jeff